Wall Street Journal
CAPITAL
By DAVID WESSEL
What's Changed
In the Protracted
Health-Care Debate
April 12,
2007; Page A7
Debating the ailments of the American health-care system is a
chronic disease. It sometimes seems the same experts have been
making the same points for decades: The U.S. spends more on
health care than other countries, but doesn't have healthier
people. Americans with generous insurance use health care
readily, and doctors provide it on demand because third parties
pay the bill. And so on.
"I remember this from 1993," former Treasury Secretary Robert
Rubin said this week at a Washington forum, recalling his years
in the Clinton administration. "Every time I think about health
care, I get a headache."
It would be easy to fill a column with the ways
in which the health-care debate never changes. But, without
offering optimism that a grand solution is imminent, three
things are now apparent that -- if not new -- at least weren't
widely appreciated 15 or 20 years ago.
Employer-based health insurance is slowly
dying.
The notion that requiring employers to provide
health insurance is the best route to universal coverage is
fading. Sure, nearly 60% of Americans still get health insurance
on the job. But even in a growing economy with a tight labor
market, employer coverage is eroding. Fifteen years ago, says
Joseph Antos of the conservative American Enterprise Institute,
"large employers were concerned about rising health spending,
but they were not leading the march to a big solution." Now they
want out.
Employers -- either through premiums or through
taxes -- will be paying part of the health-care tab for a long
time, but there is surprising interest in requiring that every
individual get health insurance, and then subsidizing those who
can't afford it.
We don't know as much about medical science
as we need to know.
It always has been true that there is a lot
about disease doctors didn't know, and it is true doctors can
cure diseases that were killers just a decade ago. But it is
also increasingly clear that ignorance about what treatments
work well and for whom is very costly, especially as new
treatments are discovered and new technologies deployed. The
flap over stents versus drugs for heart disease is only the
latest example.
"I don't think there was very much recognition
[15 years ago] about how little we know in areas that we spend
large amounts of money on...," says economist Gail Wilensky, a
former Medicare administrator now at Project Hope, a global
public-health charity. Dartmouth Medical School researchers have
been showing for decades how differently medicine is practiced
from one town to the next. There is surprisingly little
agreement on what works and what doesn't. There is, however, a
consensus that figuring that out is important and getting the
health-care system to make better use of information technology
is crucial to that end.
Americans want a lot of health care, are
willing to pay for a lot of it and don't like their choices
limited.
Maybe this isn't exactly new, but it is more
certain. Americans rebelled against managed care, and
particularly didn't like employers forcing them to enroll. "One
of the lessons of the '90s is that every consumer insists on the
right to choose a poor-quality physician," Ronald Williams,
chief executive of Aetna Inc., said at that Washington forum,
which was sponsored by the Hamilton Project, the outfit Mr.
Rubin and others founded to devise ideas for centrist Democrats.
So no matter how many experts prescribe big
integrated health-care plans as the best way to get medical
care, Americans won't be forced into them. Some may choose such
plans, but they want choice -- and politicians won't enact
legislation that denies them choice.
Politicians and employers may, however, be
willing to make Americans pay to satisfy their unlimited
hunger for health care. President Bush, no fan of tax increases,
has proposed raising taxes on those with the most generous
health plans. Jason Furman, a former Clinton and Kerry campaign
aide, floated a proposal this week that says Americans ought to
pay more for the health care they buy (with the best-off paying
more out of pocket than the poor.)
Some say the biggest change is that the anxiety
of American workers and businesses about the costs and
shortcomings of the U.S. health-care system have reached a
crescendo and something big will happen soon. Could be. But
we've heard that before.
One veteran of the health-care wars, Robert
Reischauer, the former Congressional Budget Office director who
now heads the Urban Institute think tank, observes a repeating
15-year cycle in which "building optimism and enthusiasm" about
big-time health reform is "dashed by realities and politics."
Complaints about the American health-care
system haven't -- yet -- produced the political will to do
something, particularly since that something will pinch some big
interests and generate fierce opposition no matter what form it
takes. Some things don't change.
Write to David Wessel at
Capital@wsj.com
